This is the story of one patients journey along the road of knee problems culminating in knee replacement. The patient is a 60 year old gentleman and commentary is written by Andrew Caldwell, consultant physiotherapist at Active Therapy based at the Lichfield Golf & Country Club and The Chase Golf, Health Club & Spa. It is written 5 months after surgery. Author: Dave Robinson

The build upLeading up to my total knee replacement due on December 1st 2014, I fully expected to be ‘up and running’ by February 2015. Indeed, I had even contemplated the idea of going skiing in the March.The history of my knee issues had been present for some time. When I was 20 (40 years ago), I injured my knee badly playing rugby. I needed a lateral meniscectomy (cartilage op) which left me unable to participate in sport for a considerable amount of time. From that time on I was aware that the internal condition of my knee was deteriorating slowly. By the time I was 30 I could no longer participate in contact sports like soccer or rugby, so I focussed on cricket. As I moved into my 40s the condition of my knee had worsened and at times I had to take pain killers to continue playing sport. I continued to ski but this caused me more and more discomfort as the years passed by. Eventually three or four years ago I thought enough is enough, skiing is now becoming too painful. I decided to have the joint cleaned up (arthroscopy and wash out/debridement). I had physiotherapy treatment post-operatively with my physiotherapist Andrew Caldwell and this appeared successful at the time. I returned to regular exercise participation and golf but my symptoms subsequently began to worsen and in consultation with my surgeon Tim Spalding I decided to opt for knee joint replacement (or arthroplasty).Having had a number of arthroscopic investigations over the years on the other knee as well, I guess I had been lulled into a false sense of security. When it came to the total knee replacement, I thought I’d put a bit of ice on it, do some exercises and be ‘right as rain’ in a few weeks. It was only when somebody told me that a knee replacement operation was major orthopaedic surgery that I began to realise how much more involved this journey would be.

Andrew Caldwell comments:When electing for orthopaedic procedures such as knee replacement patients need to be advised and understand that arthroplasty (joint replacement) is a significant operation with a very different recovery to arthroscopy (keyhole surgery) requiring intensive post-operative rehabilitation to achieve optimal outcome.

The initial recoveryThe operation went very well and without complication. I received excellent care as an in-patient whilst in hospital and could not have been better looked after. I had the procedure on Monday and went home on Thursday. I mastered the crutches quickly, and did all the basic exercises prescribed without any problems. When I was back at home I had been told to carry on with the flexion and extension exercises, take the pain killers to allow more movement to be achieved and then to elevate and ice the knee. I did this for a week and started to feel good about progress. Eleven days after the op I had the staples (stitches) removed and then a few days later went for my first physio session. At this meeting my knee flexion was 85 degrees and I was still short of being able to extend the knee joint fully. I was a bit frustrated by my lack of progress at this point. I consequently experienced quite a painful session on this first occasion as the Physio encouraged more bend and extension in the joint. It was December 15th. I returned home but with Christmas looming and the family starting to arrive I neglected the exercises, the painkillers and the ice. For two weeks I probably only iced once a day, took no painkillers because I wasn’t really in any pain, and did not commit anywhere near as much time as I should have to my exercise programme. It was January 5th before I went for my second physio session. My knee flexion was 80 degrees. I had lost 5 degrees of flexion through inactivity! I was also experiencing pain on the medial side of the knee. The physio was a little frustrated by my deterioration. That session was particularly painful as the physio tried to encourage more flexion and extension into a stiffening knee joint. It was impressed upon me to take the painkillers and to ice regularly. The painkillers would help to mask the pain as I did the exercises and to push myself to improve the range of movement. Finally I had got the message! But I had lost 2 – 3 weeks of potential progress due to complacency. I now realised that the only way this would work was if I was prepared to work hard and go through a bit of pain. I started hydro therapy and at the third physio session recorded 90 degrees of flexion. I was now taking the painkillers and doing as I was told!The following week (January 12th) I returned to work on a half day basis. I now think this was too soon because it was not easy to do my exercises and get ice at work.

Andrew Caldwell comments:The decision to return to work is individually specific and influenced by a patients’ occupation but encouraging the earliest and safest return to work with modified hours is advised. Patients recover better when in their normal social environment but need to arrange that they can continue rehabilitation to achieve optimal results.

By January 19th and the fourth session I was up to 100 degrees but I still had some pain on the medial (inside) of the knee. This was very localised. After the fifth session on January 26th I was up to 115 degrees and started some strengthening exercises also. Mobility was getting better and the medial pain in the knee was starting to subside. I then waited two weeks before my final physio session on February 13th. My knee bend was 125 degrees, but I still could not quite fully extend the joint. Since then I have continued to work hard on the exercises etc and I can now lock out the knee fully. I had 5 hydro therapy sessions (exercises in water) and 6 physio sessions as part of the post operative treatment and care. This was excellent.I then decided to contact Andrew Caldwell who is a consultant physiotherapist and specialises in sports injury and rehabilitation. Andrew is a colleague and friend who is connected with me through sport and work. He assessed me on February 16th 2015 and advanced my exercise programme to specifically develop strength and flexibility toward sports specific and end stage rehabilitation.

Andrew Caldwell comments:Some post-operative discomfort is normal whilst the body is recovering from surgery and typically isn’t an indicator of danger or damage to the replacement. During exercise experiencing pain up to 5/10 on a pain score (where 10 is severe pain) during exercise then this is OK. This pain should not persist for more than 30 minutes after exercise. Post exercise icing can ease discomfort.

5 months since surgeryIts now 5 months after the knee replacement and I have been doing Andrew’s exercises (there are 10 of them) everyday religiously since that date in feb. I am still going to the pool at least 3 times a week and doing my exercises in the water.I would not say my knee is 100% yet but I can do things now (e.g half squats) that I could not do before. The strength is returning quickly to my new knee. It still swells up a little especially if I have done a lot that day. But I am told this can be quite normal. This restricts the movement but it quickly returns with elevation and rest. I am not icing the knee as often, only once or twice a week. However, I did put ice on it 3 or 4 times a day up until the end of February. I have been told by Mr Spalding to start to do other more normal activities eg golf, but to take it slowly. I feel after 15 weeks that I am now getting there.

Andrew Caldwell comments:Rehabilitation needs to be advanced above the level that each patient requires for their activities of daily life or sport. During rehabilitation they need to exceed the demands placed upon their lower limb to avoid persistent symptoms of tissue overload such as pain, stiffness and swelling. For example the loading on a knee encountered during the golf swing can be equivalent to a 30cm box jump!’

What have I learnt from this?My advice to anyone thinking about having a knee replacement operation, once you have had the op, is:- take painkillers 30 minutes before you exercise- perform your exercises regularly as prescribed by your physiotherapist. Consistency is the key! - after exercising, elevate the knee and apply an ice pack for about 20 – 30 minutes.I would also advise people not to go back to work until they really do feel ready. It is so important that this operation works for you so you have to give yourself the best chance. I also suggest that after your first course of physio has finished, go and get some more. Physio’s know what they are talking about!After a really good start straight after the operation, I was complacent for 2 to 3 weeks. I thought I didn’t need painkillers, and if I just rested the swelling would go down and the mobility would return naturally. This isn’t the case. You have to push yourself and the joint to both bend and straighten. This can be painful so take the painkillers. That’s what they are for – to help you push yourself. Then get your leg up higher than your hip and put ice on it.I have been lucky, I am on the road to a very good recovery. I had an excellent surgeon and have had first class post-operative care. It may still be another couple of months before I am starting to do the things I want to. But if I had my time again I would do everything by the book right from the start. Next year I hope to ski again!

Andrew Caldwell comments:Chartered physiotherapists are rehabilitation specialists who have extensive training and specific expertise to ensure you achieve an optimal outcome from your surgery. Together the surgeon, physiotherapist and patient form a team who work together to achieve the best outcome.